System Factors and Racial Disparities in Nursing Home Quality of Life and Care Over the past decade, the proportion of minority older adults residing in nursing homes (NHs) has increased dramatically and is projected to surpass that of white adults by 2030.1 NHs account for 68% of the $72 billion spent on long-term care in 2008 with most of it funded by Medicaid. These demographic and financial realities create an urgency to understand the needs of minorities in NHs and how systems organization and care delivery in NHs operate to ensure that minority residents maintain quality of life (QoL) and receive quality of care (QoC) equitable to white residents. QoL is a patient-centered measure that captures social, psychological, and environmental well-being. QoC typically consists of staff-reported indicators of care delivery and its related to clinical outcomes (e.g., pressure ulcers). Racial disparities exist in certain QoC indicators, and our recent work for the first time found racial disparities in NH resident QoL. However, those disparities were not based on individual race/ethnicity, but reflected system-wide factors affecting NHs that served more minority residents. Some of these factors are not amenable to intervention, including location of high-minority proportion NHs in poorer areas. There is a need to identify modifiable system-wide mechanisms for these disparities to craft interventions that address them. Our long-term goal is to develop an intervention for improving QoL for minority NH residents nationwide. To build toward that goal, we designed a multi-method study to examine organizational structures and processes of care in NHs with high and low proportions of minorities, and then assess system-level predictors of NH QoL (primary outcome) and QoC (secondary outcomes) in a unique state-level database with more granular measures as well as a nationally-representative database. This study has three specific aims: Aim 1: Assess and compare, via qualitative methods, the structural, cultural, and process factors influencing QoL and QoC for minority residents among NHs with high, moderate, and low proportions of minority residents. Aim 2: Determine the effect of system-level factors on racial/ethnic differences in NH QoL(primary) and QoC (secondary outcome) using a unique statewide dataset. Aim 3: Using national data from all licensed NHs in the US, test the effect of system-level predictors on racial differences in QoL (primary) and QoC (secondary outcome).